121 Watleys End Road

Updated 25 February 2022

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

This inspection took place on 26 January 2022 and was announced. We gave the service 24-hour notice of the inspection.

Updated 25 February 2022

The inspection took place on 12 April 2018 and was unannounced. The service was last inspected in March 2017. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of is the service effective, is it responsive? and is it well led?

At the last inspection there was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Safeguarding service users from abuse and improper treatment. There was a breach of Regulation 17 of the Care Quality Commission (Registration) Regulations 2009. There was also a breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 around Person centred care. Specifically improvements were needed in relation to the Mental Capacity Act 2005 that Deprivation of Liberty Safeguards applications were promptly resubmitted for people when their authorisation had expired. Improvements were also needed, as the registered manager at the time had not submitted notifications of all incidents that affected the health, safety and welfare of people who use the service. Notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled.

121 Watleys End Road is a care home providing personal and nursing care to up to 14 people. There were 13 people living at the home at the time of our inspection. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

There was a registered manager for the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had worked for the provider for a number of years in other services. They had worked at the home for one year.

Medicines were stored securely and administered by staff who had been trained and assessed as competent to do so. Medicines were reviewed regularly to ensure people with complex needs received them appropriately.

The service was responsive to people's needs and they were able to make choices about their day-to-day routines. People had access to a range of activities, which provided them with mental and social stimulation. People were able to go into the community safely.

People were supported to feel safe at the home and with the staff who supported them. There were systems and processes in place to reduce risks to people. These included a thorough recruitment process and ensuring staff knew how to recognise and report abuse. There were enough staff available to meet people's needs in a timely way.

Staff we spoke with understood the requirements of the Mental Capacity Act 2005 Staff completed training in a range of areas including safeguarding, moving and handling, basic life support, dementia awareness and health and safety

Staff were caring and kind towards the people they supported. The staff knew people well and understood their needs. However, at certain times during our visit, some staff communication was not fully person centred. Some staff spoke to each other and did not communicate with people when they assisted them. For example, when helping people who were in wheelchairs to move. We saw staff assist people with no communication about what they were doing or why they were doing it.

We have made a recommendation around staff communication with people.

Accidents and incidents were reported and monitored to identify any patterns or trends. Relatives were asked for their views about the service and actions taken where needed. Staff we spoke with felt supported by the management and leadership of the home.

The premises were homely and were suitable for people's needs. People’s rooms showed they were involved in decisions about the decor. The environment and equipment was regularly checked and serviced.

There was a complaints procedure in place, should anyone wish to raise a complaint on behalf of people who lived at the home.

The provider's auditing systems had identified shortfalls in the service and action was being taken to address them.